A tracheostomy is a surgical procedure where a surgeon creates an opening in the anterior neck and inserts a tube into the trachea (windpipe) to facilitate breathing. Patients may require a tracheostomy due to upper airway obstruction, the need for long-term mechanical ventilation, or to facilitate secretion management. While tracheostomies can be life-saving interventions, they do carry risks of complications and mortality. Understanding the most common causes of death in this vulnerable patient population is important for healthcare providers to optimize patient safety.
Background on Tracheostomies
Tracheostomies were first performed in the early 1800s and involved a surgeon making an incision between the second and third tracheal rings. Modern tracheostomy tubes are often inserted between the first and second or second and third tracheal rings using the surgical technique known as percutaneous dilatational tracheostomy (PDT). PDT involves using serial dilators to create the stoma rather than making a surgical incision. This is now the preferred technique in many intensive care units (ICUs) as it results in less tissue trauma.
Tracheostomies are frequently performed in critically ill patients who require prolonged mechanical ventilation. Having a tracheostomy tube avoids the need for endotracheal intubation and may allow for easier weaning from the ventilator. Other indications include upper airway obstruction from trauma, tumors, vocal cord paralysis or having a large volume of respiratory secretions that cannot be managed with suctioning through the mouth or nose. There are two main types of tracheostomy tubes – uncuffed tubes which are sometimes used in pediatric cases, and cuffed tubes which allow for air to be directed solely through the tracheostomy rather than the upper airway.
Complications and Mortality
While tracheostomies can be lifesaving, they do have associated risks and complications. These can occur during the surgical procedure itself, in the immediate postoperative period, or long-term as scar tissue develops around the tracheostomy. According to research, the incidence of perioperative and immediate postoperative complications ranges from 6-66%. The wide range is likely related to differences in patient populations across studies.
Some potential early complications include hemorrhage, loss of airway, pneumothorax, subcutaneous emphysema, stoma infection, tracheitis, and tracheoesophageal fistula formation. Later complications can include tracheal granulation, tracheal stenosis, erosion into nearby vasculature, and difficulty with decannulation. Patients with tracheostomies often have complex medical problems and comorbidities which also contribute to mortality risk.
Overall reported mortality rates in patients with tracheostomies range from 10-60%. A large systematic review published in 2008 found an overall mortality rate of 26.7% in patients who underwent tracheostomy for prolonged ventilation. Patients who require a tracheostomy for upper airway obstruction had a mortality rate around 10%. Again, differences in study populations make comparisons difficult. Identifying the most common causes of death can help healthcare teams provide the best care for this high-risk group.
Most Common Causes of Death
Several studies have aimed to determine the most frequent causes of mortality in tracheostomized patients. Here is a summary of the major findings:
Sepsis/Multi-Organ Failure
Multiple studies have identified sepsis or multi-system organ failure as the most common cause of death in patients with tracheostomies, ranging from 30-60% of mortalities. Patients requiring prolonged mechanical ventilation are often critically ill and at risk of secondary infections like ventilator-associated pneumonia (VAP). Multi-organ dysfunction can then ensue, ultimately leading to death in a large proportion of cases.
Pneumonia
After sepsis, pneumonia is one of the next most frequently cited causes of mortality in this population. One study found it accounted for 14% of deaths. Pneumonia can be related to aspiration of oral secretions, impaired cough and mucociliary clearance, or occur secondary to mechanical ventilation. Ventilator-associated pneumonia in particular is linked to worse outcomes. Preventing and promptly treating respiratory infections is paramount.
Hemorrhage
Bleeding complications account for around 10% of mortalities in tracheostomy patients based on several studies. This includes hemorrhage during the surgical procedure, from the tracheostomy stoma site, or from erosion into nearby vasculature like the innominate artery. Proper surgical technique and appropriate sedation during tracheostomy placement help reduce bleeding risk.
Cardiovascular Events
Acute cardiovascular events like myocardial infarction or fatal arrhythmias account for approximately 5-10% of deaths in this population. Patients who require prolonged mechanical ventilation are often older or have underlying cardiovascular comorbidities that place them at increased risk. Careful monitoring and management of cardiac risk factors is important.
Prevention of Complications and Death
Since complications of tracheostomies account for such a high proportion of mortality, prevention is key. Several strategies can help reduce risks:
– Careful patient selection and timing of tracheostomy placement
– Utilizing percutaneous dilatational technique when appropriate
– Performing tracheostomy with bronchoscopic guidance
– Emphasis on infection control practices
– Regular stoma care and suctioning of secretions
– Downsizing the tracheostomy tube as soon as feasible
– Minimizing sedation and delirium
– Early mobility and pulmonary rehabilitation
– Tight glycemic control and nutrition
– Recording cuff pressures to prevent tracheal damage
– Angiography or CT scans if innominate artery erosion is suspected
Mortality rates have improved in recent decades with greater awareness of potential complications and focus on prevention. However, patients with tracheostomies remain a high-risk group.
Key Statistics
Here are some key statistics on mortality rates and causes of death in patients with tracheostomies:
| Overall mortality rate | 10-60% |
| Most common cause of death | Sepsis/multi-organ failure (30-60%) |
| Second most common cause | Pneumonia (14%) |
| Hemorrhage | ~10% |
| Cardiovascular events | 5-10% |
Conclusion
In summary, patients requiring tracheostomies for artificial airways represent a high-risk group with mortality rates ranging from 10-60% in published studies. The most frequent causes of death are sepsis, pneumonia, hemorrhage, and cardiovascular events. Strategies to optimize sedation, treat infections, monitor for bleeding, and stabilize cardiopulmonary status are all critical to improving outcomes in this vulnerable population. With a multimodal approach, healthcare teams can reduce morbidity and mortality related to tracheostomy complications. Further research is needed to continue refining preventive and management strategies for patients with tracheostomies.